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Medicine > OME GI > Flashcards

OME GI Flashcards

1
Q

Clinical picture consistent with choledocolithiasis progressed to ascending chilangitis with sepsis

Next step

A

ERCP
Diagnostic and therapeutic

Don’t wait for RUQ US here or MRCP, this is emergent

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2
Q

What bugs is amp gent and metro treating

A

amp gent - gram negatives

metro - anaerobes

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3
Q

Treat CAP with abx

A 
Ceftri and Azythro
or
Moxi
or
Azythro alone if not being admitted
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4
Q

TF
Pip/Tazo will cover gram negatives and anaerobes in ascending cholangitis

Necessary to add vanc?

A

T

No need for vanc

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5
Q

Ceftriaxone coverage

A

Gram positives
Gram negatives

Good skin penetration

A shotgun

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6
Q

Painless jaundice obstructive biliary labs but normal biliary tree on RUQ US in 40yo female think

A

PBC intrahepatic obstruction

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7
Q

Courvoisier’s sign

A

Palpable but non-tender gallbladder – painless distended gallbladder suggests cancer or stricture from PSC

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8
Q

Patient with risk factors (female fat forty fnativeamerican) has acute cholecystitis symptoms (RUQ pain and tenderness some fever no jaundice) but RUQ US is equivocal (some mild wall thickening gallstones biliary sludge but no pericholecystic fluid)

Next step?

A

HIDA nuclear scan

can see if gallbladder fills or obstructed cystic duct

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9
Q

TF

Doppler flow ultrasound can evaluate biliary flow

A

F
Biliary flow is too slow for doppler

Doppler usefulness is limited to vasculature – eg portal vein or hepatic vein thrombosis

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10
Q

Large esophageal ulcerations and owl eyes (large central basophilic nuclear inclusions separated by a halo) on biopsy
Dx
Tx

A

CMV esophagitis

Valgancyclovir

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11
Q

Nuclear molding with inclusion bodies on path from vesicles on an erythematous base in the esophagus
Dx
Tx

A

Herpes zoster

Acyclovir

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12
Q

TF

Herpes can cause esophagitis

A

T

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13
Q

Dysphagia esophagitis atopy by history eosinophils on biopsy you are thinking eosinophiliic esophagitis next step

A

6-8 weeks acid suppression with ppi because GERD can produce eosinophils and must rule out

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14
Q

Treat eosinophilic esophagitis

A

6-8 weeks acid suppression with ppi because GERD can produce eosinophils and must rule out

Oral budesonide when dx confirmed with failure of 6-8 weeks ppi (or another oral steroid that you usually see in inhaled form eg fluticasone)

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15
Q

TF

Gluten free improves eosinophilic esophagitis

A

F

Can be food allergy component and benefit from avoiding, but no evidence of gluten

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16
Q

Presentation
Diagnosis
Treatment
Eosinophilic esophagitis

A

Dysphagia esophagitis history of atopy

Endoscopy esophagitis and Biopsy eosinophils
6-8 wk ppi trial to r/o gerd
Repeat endoscopy
Oral formulation of a typically inhaled steroid
Avoid foods that seem to cause

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17
Q

large central basophilic nuclear inclusions separated by a halo on path
Aka
Dx
Tx

A

Owl eyes inclusion bodies
CMV
Valgancyclovir

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18
Q

Esophageal cancer suspected

First diagnostic test

A

Barium esophagram
- first test to eval esophagus for almost anything

Will get EGD scope but barium swallow first, will help id location of mass and lymph nodes eg for EUS or other EGD diagnostic adjuncts

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19
Q

Why give LR instead of NS for resuscitation of hemorrhaging pt

A

Enough NS can cause acidosis

Can compound lactic acidosis of hemorrhagic shock

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20
Q

Transfuse hemorrhaging pt to Hb of __

A

Transfuse hemorrhaging pt to Hb of 7 or improvement of symptoms

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21
Q

Treat significant upper gi bleed eg in ed

A 
2 large bore IVs
Fluid LR bolus
Type and cross transfuse as needed
IV PPI
Call GI for EGD scope

If cirrhotic - Octreotide for varices, Ceftriaxone ppx for SBP

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22
Q

Curling ulcer

Cushing ulcer

A

Curling ulcer in Burn pt

Cushing ulcer in ICU pt

Peptic ulcers…

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23
Q

All the tests for h pylori

A

Urea breath test - non invasive, active h pylori

Serology - exposure to h pylori ever

Stool antigen - monitor for eradication

Biopsy - best test to confirm dx

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24
Q

Triple therapy for h pylori

Quadruple therapy

A

PPI bid Clarythromycin 500mg bid Amoxicillin 1000mg bid (Metronidazole 500mg bid if penicillin allergic)
- less effective but more tolerable so more effective in the end

Bismuth Subsalicylate 525mg qid Metronidazole 250 qid Tetracycline 500 qid Ranitidine 150 bid

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25
Q

Achalasia in a younger patient may be a sign of _____ disease

A

Achalasia in a younger patient may be a sign of Chagas disease

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26
Q

Treat achalasia

A

Myotomy if good surgical candidate

Dilation if not

Meds and botox don’t realky work

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27
Q

Define pseudoachalasia

A

Cancer causing symptoms of achalasia

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28
Q

Corkscrew appearance of esophagus on barium swallow

Dx

A

Diffuse esophageal spasm

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29
Q

Circumferential esophageal stricture causing steakhouse dysphagia (to poorly cut or chewed food)

Aka

A

Shatzki’s ring

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30
Q

Next step on first time presentstion of probable GERD

A

PPI…. plus lifestyle modification

But PPI if only one choice – strongest therapeutic and diagnostic intervention… lifestyle evidence weak

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31
Q

When to get ambulatory pH monitoring for GERD

A

Preop
or
When PPI and lifestyle not helping, to conform symptom assoc w acid

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32
Q

GERD with emesis and dysphagia… get UGI or EGD?

A

EGD for GERD with alarm symptoms

UGI otherwise first for dysphagia, then EGD after but this case has alarm symptoms so straight to EGD

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33
Q

what CCBs for nutcracker diffuse esophageal spasm?

A

Diltiazem Verapamil
(non-cardiac)

Not nifedipine

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34
Q

describe Barret’s on EGD

A

salmon-colored lesion with intestinal metaplasia

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35
Q

manage Barret’ts esophagus

A

high-dose PPI

surveillance EGDs to eval for resolution vs progression (dysplasia, adenocarcinoma)

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36
Q

what kind of epithelium in Barrett’s esophagus

___ not ___

A

Columnar (duodenal)

not glandular (gastric)

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37
Q

treat low grade dysplasia of esophagus

vs high grade dysplasia

A

low grade dysplasia – endoscopic destruction of the lesion to prevent progression to adenocarcinoma

high grade - surgical resection, treat like adenoma

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38
Q

best test to confirm eradication of h pylori

A

stool antigen

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39
Q

3 patients who benefit from PPI PPX

and maybe a 4th

A

burn pts
icu intubated pts
high intracranial pressure pts

maybe postop pts npo for a long time

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40
Q

guess the ulcer cause:

single deep heaped up margins

single deep not heaped up

multiiple shallow

A

single deep heaped - cancer

single deep not heaped - h.pylori

multiple shallow - NSAIDS

multiple deep - Gastrinoma

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41
Q

before getting nuclear emptying study to diagnose gastroparesis in a vomiting diabetic, you must get…

A

must get an EGD first to rule out mechanical obstruction before you make swallow stuff for nuclear emptying study and diagnose gastroparesis

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42
Q

treat diabetic gastroparesis

A

glycemic control
small meals low in fiber

maybe metoclopramide or erythromycin for exacerbations but avoid long-term

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43
Q

bbw metoclopramide

A

tardive dyskinesia

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44
Q

multiple deep ulcers on EGD with elevated serum gastrin, next steps

A

secretin stimulation test to confirm Gastrinoma

CT vs somatostatin receptor scintography to identify location of lesion for surgery and stage

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45
Q

when to discontinue PPI and reassess gastrin level in setting of multiple deep gastric ulcers and high serum gastrin

A

when serum gastrin v300
(this low elevation may have been caused by compensation acid production in response to PPI

(if gastrin higher, start thinking secretin stimulation test, CT vs somatostatin scintography and surgery for gastrinoma)

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46
Q

gastrinomas (zollinger ellison syndrome) is diagnosed by

A

obtaining an elevated gastrin then secretin stim test then staging with CT or somatostatin scintography

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47
Q

lymphoma associated with h.pylori causing gastric outlet obstruction…

what kind of cancer?
how to treat?

A

MALToma

treat H.Pylori and maltoma will regress

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48
Q

camping fresh water streams and diarrhea think this bug

A

Giardia

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49
Q

most common cause of infectious diarrhea that is not viral – no risk factors given, they just ask for most common organism… what is it?

A

Campylobacter

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50
Q

causative bug in traveler’s diarrhea

A

ETEC

enterotoxigenic e coli

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51
Q

diarrhea, picnic, potato salad cooked eggs mayonnaise left out… what bug what mechanism

A

staph aureus

toxin, not actual infeciton

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52
Q

bug in chinese buffets and fried rice

A

bacillus cereus

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53
Q

bloody diarrhea, raw eggs or raw poultry, think this bug

A

salmonella

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54
Q

HIV / AIDS and diarrhea, think this bug

A

cryptosporidium

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55
Q

recent abx and diarrhea think this bug

A

c diff

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56
Q

recent abx and bloody diarrhea or toxic megacolon think this bug

A

still c diff

can present in variety of ways – watery, bloody, toxic megacolon

57
Q

bloody diarrhea, hemolytic uremic syndrome think this bug

A

EHEC O157h7

58
Q

treat

symptomatic but not severe c diff

refractory c diff

severe c diff

A

symptomatic but not severe – PO Metronidazol

refractory – Stool Transplant (better) or PO Fidaxomycin

severe - IV Metronidazole and PO Vancomycin

59
Q

TF

treat severe c.diff or c.diff that does not respond to metronidazole with IV Vancomycin

A

F
PO Vancomycin and IV Metronidazole for severe c diff

(iv vanc won’t get to gut well but iv metronidazole will)

60
Q

TF

IV vanc and metronidazole do not penetrate gut

A

Fish
IV vanc does NOT
IV metro DOES

so for severe c diff give IV metro PO vanc (po metro for symptomatic but not severe c diff)

61
Q

30yo F with chronic diarreha, abdominal pain, problems with weight loss, osteoporosis, anti-tissue transglutaminase and anti-endomysial antibodies… next step?

A

Endoscopy with Biopsy to confirm dx
-absence of microvilli

THEN Gluten Free diet, vit D and Calcium supplementation, etc

62
Q

used to treat acute diarrhea – particularly traveler’s diarrhea

A

ciprofloxacin

63
Q

suspect IBS based on chronic abdominal pain and loose stools… diagnostic workup?

A

rule out Celiac (ant-ttg, anti-endomysial antibodies, biopsy, etc)

colonoscopy to rule out IBD

f/u re sexual abuse (highly comorbid with IBS) if ruled out Celiac

64
Q

in IBD __ is bloody, __ is not

A

UC is bloody, Crohn’s is not

65
Q

young woman with iron deficiency and osteopenia despite balanced diet and exercise and no menometorrhagia

think. ..
do. ..

A

think Malabsorption, most likely Celiac Sprue (lose FIC folate iron calcium vitatmins in duodenum with malabsorption)

do Endomysial ab, TTG ab, or Endoscopy with Biopsy in search of celiac diagnosis

don’t just supplement iron and calcium without working up for diagnosis!

66
Q

Ceftriaxone and Azithromycin combo used for…

A

CAP or GC

community acquired pna
or ghonorrhea chlamydia

67
Q

most likely cause of brisk lower GI bleed in an old

best 2 distractors

A

diverticular hemorrhage (diverticulosis)

  • internal hemorrhoids usually not sufficient for hematochezia and acute blood loss… not as brisk…
  • colon cancer more likely iron deficiency anemia than overt hemorrhage
68
Q

when to get colonoscopy after diverticulitis

A

2-6 weeks

not actively inflammed, but not so long that potential cancer brews

69
Q

colonoscopy recs for UC

A

8 years after dx and then annually if no preferred colectomy

70
Q

equivalents to q10 screening colonoscopy

A

FOBTx3 annually
flex sig q5 with FOBT q3

but colonoscopy preferred for sensitivity, complete colon eval, biopsy/intervention ability

71
Q

first instinct for iron deficiency anemia in postmenopausal female or male

A

colonoscopy to rule out colon cancer

72
Q

hereditary nonpolyposis colorectal cancer
aka
family hx
screening recs

A

lynch syndrome
family hx of lady cancers and colon cancer
screen at age 20-25 yo or 10y prior to earliest family colorectal cancer

73
Q

treat FAP

natural history

A

prophylactic colectomy

thousands of polyps by age 18
colon cancer by 40
death by 50

74
Q

Gardner’s syndrome needs ___ or ___ in the vignette

A

osteochondroma or osteosarcoma of the jaw… and colon cancer

75
Q

brain tumors plus colon cancer think

A

Turcot syndrome
(wear a turban on your head - brain tumor)

brain tumor plus colon cancer

76
Q

picture of little hyperpigmented macules that look like freckles on the oral mucosa, think…

A

Peutz-Jeghers

77
Q

bronze diabetes and cirrhosis =

pathophys

dx

A

HEMOCHROMATOSIS
hyperpigmented skin, diabetes, cirrhosis

disorder of excessive iron absorption from gut… no way to excrete… builds up liver and pancreas… causing cirrhosis and diabetes

get hepatic biopsy - elevated hepatocyte iron
vs HFE gene, transferrin, ferritin

78
Q

onion skin fibrosis on liver biopsy think

A

primary sclerosing cholangitis

79
Q 
obstructive jaundice
beads on a string MRCP
male UC
ANCA
onion skin fibrosis
A

PSC

primary sclerosing cholangitis

80
Q

PAS positive hepatocytes is diagnostic of

sequelae

A

alpha-1-antitrypsin deficiency

cirrhosis and emphysema

81
Q

cirrhosis chorea Kayser-Fleischer rings think

pathophys
labs

biopsy?

A

Wilson disease

impaired Copper excretion, elevated Hepatocyte copper

serum ceruloplasmin and
urinary copper elevated

no need to biopsy – Kayser-Fleischer rings are enough (dark copper ring at outer border of iris)

82
Q

baloon degeneration and mallory bodies on liver biopsy think

A

alcoholic cirrhosis (if excess alcohol)

or NASH if alc denied denied

83
Q

pathophys of cirrhosis and emphsema in alpha-1-antitrypsin deficiency

A
  • mut in a-1-antitrypsin
  • elastase in lung unchecked
  • malformed protein accumulates in liver, granulates, inflammation, cirrhosis
84
Q

what kind of signals do you need to go from cirrhosis to thinking viral hepatitis

A

needles - hep c
prostitutes or asia - hep b

and positive serologies

85
Q

cirrhosis and COPD think

A

alpha-1-antitrypsin deficiency

86
Q

40-50yo F painless jaundice, cirrhosis, normal biliary imaging think

diagnose?

A

PBC primary biliary cirrhosis

diagnose with Anti-Mitochondrial antibody

87
Q

Anti-Smooth antibody cirrhosis think

A

autoimmune hepatitis

88
Q

p-ANCA liver stuff think

A

PSC - hx UC then cirrhosis or obstructive jaundice with MRCP beads on a strig in male

89
Q

ceruloplasmin level in Wilson’s disease

A

decreased

-too much copper binds it and uses it up

90
Q

anti-Smith antibodies think

A

Lupus

91
Q 
diagnoses associated with these antibodies anti:
Smith
Mitochondrial
p-ANCA
Smooth
A

Smith - lupus
Mitochondrial - PBC
p-ANCA - PSC
Smooth - autoimmune hepatitis

92
Q

pt with cirrhosis and multiple complications (varices, angiomas, etc) and now ascites… next step CT or Paracentesis?
why?

A

Paracentesis - to rule out SBP spontaneous bacterial peritonitis (SBP if ^250 polys)… even if not tender…

imaging will only confirm what you already know

93
Q

if pt has ascites

A

do a paracentesis

94
Q

treat hepatic encephalopathy

A

lactulose (traps ammonia in gut as ammonium)

rifaximin

zinc

95
Q

why ciprofloxacin in setting of cirrhosis

A

ppx against sbp

96
Q

why furosemide and spironolactone in setting of cirrhosis

A

treat ascites

97
Q

why propanolol in setting of cirrhosis

A

decrease portal pressures and vericeal bleed risk

98
Q

consider TIPS when

A

endoscopic banding fails to control cirrhotic variceal bleeding

99
Q

ascites with GI bleed, what to do soon as bleed controlled

A

ppx against SBP with ceftriaxone

100
Q

treat pancreatitis

treat necrotizing pancreatitis

treat pancreatitis with fevers and infection confirmed on biopsy

A

fluids, analgesia, bowel rest

fluids, analgesia, bowel rest

ok now with HARD evidence of infection you can start MEROPENEM vs ceftri/flagyl vs cipro

101
Q

acute pancreatitis by symptoms and lipase, pt on fluids, analgesia, bowel rest, next step CT or RUQ US?

A

RUQ US - common causes of pancreatitis in us are alcohol and gallstones, so rule out gallstones

CT rarely indicated for acute pancreatitis… more for poor clinical progression to assess for necrosis or secondary symptom workup

102
Q

why is lipase and not amylase the test of choice for pancreatitis

A

amylase elevated in gallbladder disease and emesis as well… less specific

103
Q

when CT for panreatitis

A

not usually

for poor clinical progression to assess for necrosis or workup of secondary symptoms… or if seems like pancreatitis but lipase is normal

104
Q

what to do for classic symptoms of pancreatitis but normal lipase?

A

CT abdomen

get dx before tx moving to ivmf npo analgesia ruq us etc

105
Q

why bowel rest for pancreatitis

A

decrease pancreatic secretions and autodigestion

106
Q

Cyclosporine use in IBD

A

UC Flares Refractory to steroids

107
Q

treat acute crohn’s flares with

A

steroids

108
Q

Mesalamine use in IBD

A

IBD limited to rectum, where mesalamine is released

109
Q

meds for maintanence of Crohns

A

mesalamine (mild)
azathioprine (mod)
rituximab (mod)
infliximab (severe)

110
Q

UC presents with

A

bloody diarrhea and tenesmus

111
Q

TF
a fistula requiring surgery makes crohns “severe”

what drug to use

A

T
fistula = severe

escalate to infliximab (anti-TNFa)

112
Q

macrocytic anemia in setting of IBD hints at inflammation where

A

terminal ileum where B12 is absorbed

113
Q

intrahepatic cholestasis can be caused by 3 things

A

sepsis, meds, cirrhosis

114
Q

isolated elevation in D.Bili and Alk Phos in setting of sepsis or other inflammatory condition think

A

Biliary Cholestasis

115
Q

painless jaundice in UC patient with high D.Bili… next step RUQ US or MRCP?

A

MRCP for beads on a string

ruq us for gallstones less helpful in absence of pain

116
Q

antiviral therapies for HepC

A

Ribavarin plus Interferon
-genotypes 1,4

Boceprevir
-genotpyes 2,3

117
Q

serial aminotransferases is a strategy for what hepatitis virus

A

chronic HepB
monitor without treating until active hepatitis arises (elevated Aminotrasferases) – then Biopsy for fibrosis and consider Antiviral… not the go-to because hepb disease does not progress unless active and antiviral therapy is life long and risks failure

118
Q

we can cure Hep_

A

we can cure HepC

Ribavarin plus Interferon
-genotypes 1,4

Boceprevir
-genotpyes 2,3

119
Q

you can only have acute Hep_ and if you do, you are sick

A

HepA is acute and sick only, not chronic

120
Q

what hepatitis serologies contraindicate blood donation

A

HepBeAg
HepBsAg
HepCAb (without treatment)

121
Q

guy on cruise gets hepatitis with aminotransferases into the 1000s, think acute Hep_

A

acute HepA (fecal oral)

acute hepb more sex and drugs, blood transfer

122
Q

Hep_ is always chronic, never obliterating liver or causing AST ALT into the 1000s

A

HepC is always Chronic, it smoulders

Hepatocellular Carcinoma and Cirrhosis but does not destroy liver with super high ast/alt

123
Q

Hep_ is B plus

A

HepD is B plus

does not work without coinfection with hep b, just makes hep b worse

124
Q

Hep_ is for pregnant women in 3rd world countries, if you see USA rule it out

A

HepE is for pregnant women in third world countries

125
Q

guy with HepC but minimal cirrhosis, how often to screen for HCC?

A

no need

only do HCC screening in cirrhotics, and comorbid HepC or HIV increases surveillance, also HCC screen HepB even if not cirrhotic (more oncogenic)

126
Q

who to screen for Hepatocellular Carcinoma

and how

A

Cirrhotics - inc freq if comorbid HepC or HIV

HepB even without cirrhosis (more oncogenic than hepc)

Ultrasound AND AFP every 6 mos

127
Q

24yo with depression, hand tremor with activity, involuntary jerking movements, non-tender enlarged liver with modest AST ALT elevation

diagnosis
treat

A

Wilson disease
genetic Hepatic Copper accumulation, leak from hepatocytes deposit in Cornea and Basal Ganglia among others

treat with chelators - D-Penicillamine, Trientine….
Zinc (interferes w copper absorption)
Transplant if fulminant hepatic failure

128
Q

liver disease and neuropsychatric symptoms in young adult think

A

Wilsons disease

genetic Hepatic Copper accumulation, leak from hepatocytes deposit in Cornea and Basal Ganglia among others

treat with chelators - D-Penicillamine, Trientine….
Zinc (interferes w copper absorption)
Transplant if fulminant hepatic failure

129
Q

3 diagnostic requirements for acute liver failure

eg differentiating ALF from acute hepatitis

A

ALT AST ^1000 (severe acute liver injury)

Confusion, Asterixis (signs of hepatic encephalopathy)

INR^1.5 (synthetic liver dysfunction)

130
Q

how does lactulose or lactitol work eg to treat cirrhotic hepatic encephalopathy

A

lactulose lactitol metabolized by colonic bacteria into acid that converts ammonia to ammonium (Ammonia Trap) and causes bowel movements which all facilitates fecal nitrogen excretion – titrate to 2-3 semiformed stools daily

131
Q

altered mental status, ataxia, nystagmus in alcoholc think

A

Wernicke Encelphalopathy (low thiaimine)

132
Q

weeks of lower abdominal pain, bloody diarrhea, fecal urgency, now with acute worsening fever, abdominal distension, leukocytosis, hypotension, and tachycardia

diagnosis
workup
treatment

A

suspect IBD now with Toxic Megacolon (may be first presentation of IBD)

Upright abdominal XRay - huge colon ^6cm diameter

bowel rest, nasogastric suction, steroids and broad spectrum antibiotic (if IBD) or metronidazole (if C.Diff)

133
Q

diarrhea cramps foul-smelling stool bloating, recent travel to developing country, benign abdominal exam

think
what if chronic
diagnose
treat

A

giardiasis

if chronic - malabsorption, weight loss, persistent gi distress

Stool Antigen Assay (immunofluorescence or ELISA)
alternatively stool microscopy for oocysts and trophozoites

Metronidazole

134
Q

traveler with diarrhea treated with ciprofloxacin is being treated for…

A

E.Coli (most common) travelers diarrhea

135
Q

patient with alcoholic liver cirrhosis by history, physical, labs, and ultrasound… further workup?

A

EGD for Esophageal Varices

major cause of morbidity and mortality in cirrhotics

136
Q

alcoholic cirrhotic with esophageal varices on EGD

treat

A

Endoscopic Variceal Ligation (preferred if large)
OR
Nadolol or Propanolol - beta blockade allows alpha constriction of mesenteric arterioles and decreased portal flow

137
Q

TF

an alcoholic cirrhotic with varices on EGD is a transplant candidate

A

F
not without Variceal Bleeding or Encephalopathy or some other sign of decompensation…. and alcohol abstinence for 6 mos

138
Q

treat ascites due to cirrhosis

A

Furosemide and Spironolactone 1st line

Therapeutic Paracentesis if respiratory compromise or abdominal discomfort

Medicine (13 decks)

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